護理師評估病人的跌倒風險。哪些因素應被識別為高風險？（選所有適合的）
A nurse is assessing a client for fall risk. Which factors should the nurse identify as high-risk? (Select all that apply.)
- AHistory of a recent fall✓ 正解近期有跌倒史
- BUse of antihypertensive medications✓ 正解使用抗高血壓藥物
- CPrescription for a sedative/hypnotic✓ 正解處方鎮靜劑/安眠藥
- DAdequate lighting in the room房間照明充足
- EImpaired gait or balance✓ 正解步態或平衡功能受損
跌倒預防是護理安全的核心議題，尤其針對老年病人。風險因子通常分為內在與外在。A（近期跌倒史）是預測未來跌倒最強力的指標。B（降血壓藥）可能導致姿勢性低血壓，引發暈眩。C（鎮靜催眠藥）會影響認知與平衡感，增加夜間下床危險。E（步態與平衡障礙）直接影響物理穩定性。選項D（充足的照明）反而是預防跌倒的防護措施，而非風險因素。護理師在評估時，必須系統性地檢查病人的藥物清單、過去病史、行動能力以及周遭環境。一旦發現風險，需立即啟動預防計畫，如設置床欄、呼叫鈴觸手可及、夜間照明，並教育病人緩慢變換姿勢。跌倒不僅造成身體傷害，更會導致病人心理上的恐懼，進而影響復健意願，形成惡性循環。
Fall prevention is a core issue in nursing safety, especially in older adults. Risk factors are generally divided into intrinsic and extrinsic. A (a recent fall) is the strongest predictor of future falls. B (antihypertensive medications) may cause orthostatic hypotension and dizziness. C (sedative/hypnotic medications) impairs cognition and balance, increasing the risk of nocturnal falls. E (gait or balance impairment) directly affects physical stability. Option D (adequate lighting) is a protective measure rather than a risk factor. When assessing, the nurse must systematically review medication lists, past medical history, mobility, and environment. Once risk factors are identified, a prevention plan should be initiated immediately—such as raising bed rails, ensuring the call light is within reach, providing nighttime lighting, and teaching the client to change positions slowly. Falls cause not only physical injury but also psychological fear, which can reduce participation in rehabilitation and create a vicious cycle.
美國護理機構廣泛使用 Morse Fall Scale 或 Hendrich II 模型進行結構化評估，且護理師需在電子病歷系統中強迫輸入評分；台灣護理師亦有類似的跌倒風險評估表（如自編版或黃金模型），但更強調護理師的臨床直覺與照服員的配合。